Key Points
- Use the highest‑yield diagnostic test early; do not let testing delay time‑critical therapy.
- Set objective targets and reassess frequently.
- Plan definitive source control or disease‑specific therapy when indicated; document follow‑up and patient education.
Algorithm
- Start antibiotics and fluids; risk-grade with Tokyo criteria.
- Arrange urgent ERCP for moderate-to-severe disease or persistent obstruction.
- Tailor antibiotics to cultures; complete definitive biliary therapy to prevent recurrence.
Clinical Synopsis & Reasoning
Charcot triad (fever, jaundice, RUQ pain) ± hypotension/AMS suggests cholangitis. Start broad-spectrum antibiotics and obtain urgent biliary decompression (ERCP) in moderate-to-severe cases per Tokyo Guidelines; correct coagulopathy and fluids.
Treatment Strategy & Disposition
Stabilize ABCs. Initiate guideline‑concordant first‑line therapy with precise dosing and continuous monitoring. Escalate to advanced/procedural interventions based on explicit failure criteria. Define ICU, step‑down, and ward disposition triggers; involve specialty teams early.
Epidemiology / Risk Factors
- Risk varies by comorbidity and precipitants; see citations for condition‑specific data.
Investigations
| Test | Role / Rationale | Typical Findings | Notes |
|---|
| LFTs, blood cultures, and ultrasound/CT/MRCP | Diagnosis | Biliary obstruction with infection | Risk grade per Tokyo |
| Risk assessment (Tokyo I–III) | Severity | Guide timing of ERCP | — |
| Coagulation studies and platelet count | Safety | Procedure readiness | — |
High-Risk & Disposition Triggers
| Trigger | Why it matters | Action |
|---|
| Sepsis/shock or acute organ dysfunction | Severe (Tokyo Grade III) | ICU; urgent biliary drainage (ERCP/IR) |
| Persistent obstruction despite antibiotics | Ongoing infection source | ERCP within 24 h |
| Recurrent cholangitis or stones | Recurrence risk | Definitive biliary therapy (cholecystectomy/stenting) |
| Coagulopathy | Procedure risk | Reversal/optimization pre-ERCP |
| Elderly/frail with poor support | Safety | Admit; multidisciplinary care |
Pharmacology
| Medication/Intervention | Mechanism | Onset | Role in Therapy | Limitations |
|---|
| Piperacillin-tazobactam/cefepime + metronidazole (per local) | Antibiotics | Hours | Cover enteric Gram-negatives/anaerobes | Tailor to cultures |
| ERCP for drainage ± sphincterotomy/stent | Source control | Hours | Definitive therapy | Percutaneous drain if ERCP not feasible |
| Vitamin K/platelets as needed | Procedure safety | Hours | Reduce bleeding risk | — |
Prognosis / Complications
- Outcome depends on timeliness of diagnosis and definitive therapy; monitor for complications.
Patient Education / Counseling
- Provide red‑flag education, adherence guidance, and explicit return precautions; arrange timely specialty follow‑up.
References
- Tokyo Guidelines for acute cholangitis — Link